Developing Competence in Pediatric Psychology within a General Child Internship Jennifer C. West, PhD. University of Rochester Medical Center Departments of Psychiatry and Pediatrics April 17, 2009

Objectives Describe an elective rotation designed to promote emerging competence in pediatric psychology Describe the challenges associated with integrating a specialized elective experience within a generalist internship program Highlight outcomes of the elective experience

University of Rochester Medical Center Internship – Child and Adolescent Track 4 interns 12 months outpatient (10-12 weekly patient contacts, groups) 6 months acute psychiatry (testing/consultation/treatment) 6 months elective with higher outpatient caseload 8 hours Pediatric Psychology 8 hours Research 4 hours Pediatric Psychology/ 4 hours Research Seminars: Psychotherapy, Diagnostic Clinic, Group Therapy, Multicultural (1/xmo), Teaching/Case Conference (1x/mo), Professional Development (1x/mo)

Pediatric Psychology Elective Development of the elective was guided by 2003 Society of Pediatric Psychology Task Force Report on Training of Pediatric Psychologists (Spirito et al) Also informed by training experiences of faculty supervisors What was positive about their training experiences and what they would have changed

Taskforce Recommendations (Spirito et al, 2003) Training in a variety of skills – direct service, research, consultation, program development and evaluation Focused training in 1-2 areas of interest with goal of developing specialization Practice in primary care Interdisciplinary training Mentoring

Domains of Training (Spirito et al., 2003) Life-span Developmental Psychology and Psychopathology Child, Adolescent and Family Assessment Intervention Strategies Research Methods and Systems Evaluation Professional, Ethical and Legal Issues Pertaining to Children, Adolescents, and Families Issues of Diversity Role of Multiple Disciplines in Service Delivery Systems Prevention, Family Support, and Health Promotion Social Issues Affecting Children, Adolescents, and Families Consultation and Liaison Roles Disease Process and Medical Management

Pediatric Psychology Elective Supervisors: Psychology Faculty and Psychology Fellows Provide consultation, assessment, and short-term treatment in the following ambulatory clinics at the Golisano Childrens Hospital at Strong: General Pediatrics Pediatric Diabetes Clinic Pediatric Gastroenterology Clinic Pediatric Pulmonology Clinic Provide psychological treatment to patients with chronic illness in the outpatient psychiatry clinic

Pediatric Psychology Elective Aims to promote development of foundational and core competencies that are integral to the internship, within a specialized context (Kaslow, 2004) And, development of specialty competencies Developmental model of competence Interns arrive with varying levels of experience and different training goals Minimum threshold of competence, yet tailor to the individual training/ professional development goals Training that combines didactic, experiential, and mentoring components

Internship Competencies Professional Skills and Competencies Diagnostic and Assessment Skills Treatment, Consultation and Administrative Skills Professional Standards and Behavior Ethical Understanding and Behavior Professional Development and Demeanor Academic Competencies Teaching and Supervision Scholarship

Pediatric Clinical Experiences: Goals and Domains of Training Training in a variety of skills: direct service, consultation Some opportunities for program evaluation and development Fewer opportunities for research Training in 1-2 specific areas of interest Interdisciplinary training Interdisciplinary settings (medicine, nursing, social work, nutrition, education-liaison, Child Life) Some joint training opportunities with pediatric residents Mentors Paired with faculty, postdoctoral fellows Developmental process

Clinical Experiences: Goals and Domains of Training Emphasis on primary care Provide consultation and service in general pediatric clinic Involved in mental health screening initiative to enhance detection of behavioral/emotional health concerns Provide evaluation/treatment to patients/families who are at- risk Educate primary care providers re: psychosocial treatments Consultation, didactic lectures Provide psychoeducation, anticipatory guidance to prevent mental illness Identify/refer patients who need ongoing mental health treatment

Clinical Experiences: Goals and Domains of Training Lifespan Developmental Psychology Supervised clinical cases across the lifespan that focus on issues related to chronic illness (e.g. adherence, procedure- related anxiety, illness management at transition to college) Area for improvement: Infancy Lifespan Developmental Psychopathology Participation in routine mental health screening initiative to identify youth at risk for mental illness Observe and conduct supervised clinical activities with patients presenting with range of psychopathology Area for improvement: acute medical illness

Clinical Experiences: Goals and Domains of Training Child, Adolescent and Family Assessment Multiple opportunities for assessment related to adherence, quality of life, coping, pain, weight control, health beliefs Assessment of family functioning – strengths, vulnerabilities Area for improvement: Increased use of empirically based assessment tools Intervention Strategies Opportunities to observe supervisors conduct interventions Opportunities to deliver interventions with children with chronic medical and behavioral health conditions (e.g., encopresis, recurrent abdominal pain, procedure-related anxiety, adjustment issues, adherence to medical regimens) Fewer opportunities for bereavement counseling, group interventions

Clinical Experiences: Goals and Domains of Training Research Methods and Systems Evaluation No current formal opportunities Professional, Ethical, and Legal Issues Pertaining to Children, Adolescents, and Families Multiple experiences focused on developing appropriate communication in healthcare settings (progress notes, evaluation summaries, interdisciplinary team meetings) Issues of Diversity Multiple opportunities for supervised service delivery to patients of diverse ethnic and cultural backgrounds, sexual orientations and to conduct evaluations using interpreter services Area for improvement: Currently only in one setting (ambulatory)

Clinical Experiences: Goals and Domains of Training Role of Multiple Disciplines in Service Delivery Participate in multidisciplinary staffings Lectures to medical students and residents, observed visits Area for improvement: participation in regular team mtngs Prevention, Family Support, and Health Promotion Supervised experience in promoting healthy lifestyles, especially related to physical activity, diet, sleep hygiene, family violence, effective discipline

Clinical Experiences: Goals and Domains of Training Social Issues Affecting Children, Adolescents, and Families Service in primary care aimed at reducing barriers to accessing mental health care Consultation and Liaison Roles Multiple opportunities to observe and provide consultation to medical providers (primary care and subspecialty), as well as to educators Area for development: no current involvement on inpatient C-L team Disease Process and Medical Management Clinics provide multiple opportunities to gain knowledge of disease process and treatment

Pediatric Supervision Group Meets weekly for one hour Participants: All trainees (interns, fellows) providing service in the Pediatrics Department Case discussions weekly (30 min) Weekly didactic presentations (30 min) 1st week of month: Guest Lecturer 2 nd week of month: Treatment presentation 3 rd week of month: Journal article review 4 th week of month: Multicultural presentation

Pediatric Supervision Group Case discussions Provide additional opportunities for trainees to gain knowledge about chronic illness and related psychosocial factors beyond clinics where they are providing service Case-based learning – focus on assessment strategies, differential diagnoses, treatment planning, interventions, ethical issues, issues related to diversity, systems issues Role modeling by supervisors Role plays Discussion of community resources

Pediatric Supervision Group Directed readings focused on domains of training (Spirito et al, 2003) Handbook of Pediatric Psychology (Ed. Roberts) Binder of articles – general issues, illness-specific Web-based resources –Bright Futures toolkit, American Academy of Pediatrics, community resources Journal of Pediatric Psychology – series of review articles on EBTs, current volumes Attendance at Pediatric Grand Rounds Additional instructional techniques could include videotapes, demonstrations with standardized pts, virtual-reality based peds psych interactive training materials

Guest Lecturer Topics Psychological Consultation in Medical Settings Psychosocial Aspects of Chronic Illness Neuropsychological Sequellae of Chronic Illness Child Life Services Education Liaison Services in the Medical Center Sickle Cell Disease Eating Disorders Understanding Behaviors of Families in Poverty Motivational Interviewing Nutrition and Pediatric Diabetes

Treatment Presentation Emphasis on empirically validated treatments of common behavioral health conditions Topics have included: EncopresisProcedure-related anxiety Recurrent abdominal painEnuresis PicaAdherence Vocal cord dysfunctionHabit cough Feeding DifficultiesSleep Problems Adjustment to IllnessWeight management

Multicultural Topics Multicultural Factors Related to Engagement and Attrition Working with Amish Families Jehovahs Witnesses and Medical Procedures Working with Refugee Families Working with Families of Greek Heritage Culture of the Single Father Cultural Issues Related to the Use of Physical Punishment Working with Families of Latino Heritage

Assessment of Competence Interns receive oral and written feedback after each patient contact, at mid-way point of the elective, and at the conclusion of the elective experience Formative and summative feedback Development and periodic review of learning plans Attempt to incorporate self-assessment informally Additional assessment tools Portfolios 360-degree evaluations Standardized patients

Formative Assessment of Competence Date:Supervisor:Trainee: Child (1 st init):Activity:Clinic: Strengths: Goals/Areas for Continued Development:

Feedback Interns provide written feedback on the elective, (clinics, supervision group, supervisors) bi-annually Feedback is solicited by supervisors and during monthly meetings with the Training Director All training faculty and interns have a bi-annual retreat during which trainees can provide feedback about all aspects of the training program, including the pediatric elective experience

Challenges Funding Competing demands (for interns and faculty) Scheduling constraints – interns may not be able to participate in some clinics Range of prior experience among interns Requires high degree of individualizing to ensure that each trainees goals for the experience are met

Challenges Meeting intern expectations Importance of truth in advertising May require modifying some goals (some may become a focus of postdoctoral training) High no-show rates in some clinics Mental health stigma (patients and medical providers) Continuing need to re-educate medical providers about training of interns and role of psychologists Mentorship of faculty

Future Directions Inclusion of inpatient and community settings Clinical experiences with neonatal populations Research experiences Group therapy experiences with children with medical illness Increased opportunities for program development and evaluation Obtain funding for the elective Increase networking with other training programs

Outcomes Popular elective : 26 interns have participated (74%) 10 did a blended elective Interns give highly positive evaluations of supervisors, supervision group, practica settings Evaluations of interns indicate that they attain or exceed expected level of competence

Outcomes 14 interns obtained fellowships with a pediatric psychology focus 7 former interns work in settings that include a pediatric psychology focus 4 trainees obtained faculty psychologist positions at medical centers 2 have psychologist positions within a school-based health clinic 1 has a psychologist position within a pediatric practice